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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # <br />SERVICE REQUEST # <br />HOME or MAILING ADDRESS <br />t- Ilk 0OO 3osb <br />SO OO$(Q(7 <br />OWNER / OPERATOR <br />2Q� STJQNl <br />NEA <br />H&S Energy Products, LLC <br />CHECK If BILLING ADDRESS <br />FACILITY NAME <br />O A <br />q <br />MEN <br />H&S Energy Products, LLC #3083 <br />HT <br />SITE ADDRESS <br />ACCEPTED BY: ^�� �j� <br />EMPLOYEE #: —1 Sa <br />DATE: <br />ASSIGNED TO: ,, <br />3775 <br />I <br />N. Tracy Blvd <br />Date Service Completed (if already completed): <br />Tracy <br />953A.d. <br />Street Number <br />Dire, cm <br />Fee Amount: t S b— <br />Street Name <br />cI <br />1 Payment Date <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />Payment Type O C— <br />Invoice # <br />2860 <br />Check #(�o )I �,3 7 <br />N Santiago Blvd <br />Street Number <br />Street Name <br />CITY Orange <br />STATE ZIP <br />CA 92867 <br />PHONE #1 E%I'. <br />APN# <br />LAND USE APPLICATION# <br />(714 )761-5426 <br />PHONE #2 En. <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />CHECK if BILLING ADDRESS <br />BUSINESS NAME <br />PHONE # EXT. <br />HOME or MAILING ADDRESS <br />FAX # <br />CITY STATE ZIP <br />BILLING ACKNOWLEDGEMENT: 1, the undersigned property or business owner, operator or authorized agent of same, <br />acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project <br />or activity will be billed to me or my business as identified on this form. <br />I also certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards, STATE and FEDERAL laws. <br />APPLICANT'S SIGNATURE: I-- 1111 b <br />11/08/22 <br />PROPERTY/ BUSINESS OWNER❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZEDAGENT El Manager <br />If APPLICANT is not the BILLING PARTY Proof Of authorization t0 sign is required Title <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property 19Cated at the <br />above site address, hereby authorize the release of any and all results, geotechnical data and/or envir mental/sI assessment <br />information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available th Same time it is <br />provided to me or my representative. PAI._ rQ PA,- <br />TYPE <br />SA ,_ <br />TYPE OF SERVICE REQUESTED: <br />R ! <br />y <br />COMMENTS: <br />NOV S4N <br />2.7 <br />2Q� STJQNl <br />NEA <br />0 <br />ANVRON/NCy <br />CTH DEPART <br />O A <br />q <br />MEN <br />HT <br />T <br />ACCEPTED BY: ^�� �j� <br />EMPLOYEE #: —1 Sa <br />DATE: <br />ASSIGNED TO: ,, <br />EMPLOYEE M %-i 7SC1 <br />V <br />DATE: t I 0 - Z -Z <br />Date Service Completed (if already completed): <br />SERVICE CODE: p b <br />PIE: 1 b02 <br />Fee Amount: t S b— <br />Amount Paid <br />I <br />t Sb1 <br />1 Payment Date <br />I I- b- Z Z <br />Payment Type O C— <br />Invoice # <br />Check #(�o )I �,3 7 <br />Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />